Location and Provider Key to Medicare Cost for Radiation Tx

Hawaii is a bargain

Action Points

Factors unrelated to the patient or disease account for the largest share of variation in the cost of radiation therapy for Medicare patients, suggesting inefficiency in current fee-for-service reimbursement.

Variations in the cost of radiation therapy are mostly driven by the location from which that care is delivered and individual patient providers.

Variations in the cost of delivering radiation therapy to Medicare beneficiaries for breast, lung, and prostate cancer does not depend on either patient or disease-related factors but rather is mostly driven by the location from which that care is delivered and individual patient providers.

Using data from the SEER-Medicare linked database, investigators found that the median cost of a course of radiation therapy delivered to 55,288 patients was $8,600 (Interquartile range: $7,300-$10,300) for breast cancer; $9,000 ($7,500-$11,100) for lung cancer, and $18,000 ($11,300-$25,500) for prostate cancer.

Factors associated with the patient or the patient's tumor accounted for less than 3% of the total variation in the cost of radiation therapy for all three cancer types.

In contrast, factors unrelated to the patient, including the year of diagnosis, where patients received treatment and individual patient providers, accounted for 44% of the variation in cost for radiation therapy for breast cancer, 43% of the variation in cost for lung cancer, and 61% of the variation in cost for prostate cancer.

The type of radiation therapy patients received also accounted for a large portion of the variation in treatment costs, ranging from 15% for prostate cancer to 27% for breast and 30% for lung cancer.

"In an efficient payment system, reimbursement of health care services should vary based on factors related to the patient, disease, or patient case complexity," Anthony Paravati, MD, Moores Cancer Center, University of California San Diego, La Jolla, California and colleagues write in the Journal of Oncology Practice.

"The geographic region of treatment delivery affected the cost of radiation therapy," the authors note, "with the lowest cost in Hawaii and the highest cost in Washington State."

"The key finding of this study -- that variability in Medicare reimbursement for radiotherapy does not depend on patient or disease-related factors -- suggests substantial inefficiency with the current Medicare reimbursement framework."

A spokesperson for the American Society for Radiation Oncology (ASTRO) told Medpage Today that ASTRO leadership plans to submit a written response to the findings. Although ASTRO offered no specific comments at this point, the spokesperson noted that the Paravati study used Medicare data through 2009, whereas complete data now extend through 2013.

The SEER program, supervised by the National Cancer Institute, represents a collection of individual cancer registries across the US covering 28% of the U.S. population.

Investigators focused on breast, prostate, and lung cancers in this particular study because they are the most common malignancies treated with radiotherapy in this patient cohort.

Patients with breast cancer who underwent breast-conserving surgery and those with lung or prostate cancer receiving definitive radiotherapy without surgery were included in the analysis.

In contrast, radiation delivered in the inpatient setting was not included because of the inability to separate reimbursement for inpatient radiation therapy from other charges incurred duration hospitalization.

They evaluated brachytherapy delivered with external-beam radiation alone or as definite treatment as well.

For each patient, radiation therapy billing claims were evaluated for the associated Unique Physician Identification Number or the National Provider Index number which correspond to either the treating physician or the clinical practice where the radiation was delivered.

The cost of a course of radiation therapy for each individual patient was defined as the summation of Medicare reimbursements from radiation therapy-related claims.

Patient and tumor-related variables from SEER included age at diagnosis, sex, race, marital status, geographic location, tumor and nodal stage, primary tumor laterality for breast and lung cancers, and median household income determined from 2000 US Census tract data.

The total cost of radiation therapy for all 55,288 patients included in the study was estimated to be $831,275,000.

"Regional differences were noted with respect to variability in cost," investigators observe.

For all three cancer types, less than 5% of the variation in cost was explained by patient or tumor characteristics in most of all SEER regions.

In contrast, factors not attributable to the patient accounted for more than 20% of the variability in cost in all SEER regions again for all three cancers.

"In prostate cancer specifically, factors not attributable to the patient accounted for >50% of the cost variability in most [of] all SEER regions," researchers point out.

The type of radiation therapy delivered to the patient also accounted for 10% or more the variation in cost in all SEER regions, they add.

Interestingly, the type of radiation therapy had a greater impact on the variability in cost in both breast and lung cancer than in prostate cancer.

As investigators also note, the cost of delivering radiation therapy increased from 2004 through to 2007, decreased uniformly across all disease sites between 2007 and 2008, and resumed an upward trend again in 2009.

Limitations in the study include the fact that SEER Medicare data do not contain information on patient anatomy, body habitus or other physical examination findings, so investigators did not have any insight into the technical complexity of each patient case.

"These factors could influence the delivery of radiation and explain a portion of the cost variation," they suggest.

The selectivity of the study cohort also suggests that the current analysis does not fully represent the entire Medicare population or indeed the rest of the U.S. population.

The dataset used also did not include younger patients or those with managed care plans or private insurance.

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